Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
7E
0F
Potential for minimal harm
0A
0B
0C
June 4, 2026Standard inspection · 7 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure appropriate respiratory services were provided for 2 (Resident #16 and Resident #34) of 3 residents reviewed for respiratory services. Specifically, the facility failed to ensure Resident #16's supplemental oxygen use was consistently documented in their medical record and failed to ensure Resident #34's Non-Invasive Ventilator (NIV) settings and supplemental oxygen use were reflected in the resident's electronic medical record
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, facility policy review, and review of manufacturer package insert, the facility failed to ensure expired medications were discarded from 2 (400 and 500 Hall medication carts) of 3 medication carts reviewed for medication storage.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, interview, facility document review, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable disease and infections when staff failed to do the following:- Ensure hand hygiene was completed between residents, which affected 3 (Resident #62, Resident #67 and Resident #21) of 5 residents observed during meal service.- Clean and store respiratory equipment for 2 (Resident #34 and Resident #16) of 3 residents reviewed for respiratory care.- Ensure the emergency cart was clean and suction tips were not open and exposed for 1 of 1 emergency carts observed.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to treat residents in a manner that maintained or enhanced the resident's dignity and respect in full recognition of his or her individuality for 2 (Resident #15 and Resident #46) of 2 residents reviewed for dignity.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 2 (Resident #1 and Resident #22) of 2 residents who had medications at their bedside and were assessed by the interdisciplinary team (IDT) to determine if they were clinically appropriate and safe to self-administer their medications.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident room was in good repair and homelike, which affected 2 (Resident #65 and Resident #66) of 4 residents reviewed for environmental concerns.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to ensure they developed and implemented comprehensive person-centered care plans for 1 (Resident #5) of 1 resident reviewed for hospice services and 1 (Resident #34) of 3 residents reviewed for respiratory care.
July 17, 2024Standard inspection · 5 citations
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed provide residents or their representatives a written notice of transfer or discharge prior to residents departing the facility for two (#28 and #49) of three sampled resident reviewed for transfer and discharges. A Long Term Care Facility Application for Medicare and Medicaid form, dated 07/14/24, documented 58 resident resided in the facility.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. alternatives to the use of bed rails were attempted prior to the use of bed rails; b. bed rails were inspected for proper fit and condition prior to use of the bed rails; c. residents and their representatives were educated on the risks and benefits of bed rails prior to the use of bed rails; and d. informed consent from the resident or their legal representative was obtained prior to attaching a bed rails to the bed for three (#19, 28, and #49) of four sampled resident reviewed for accident hazards. The Administrator identified 25 resident that had bed rails attached to their beds.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interview, the facility failed to implement a comprehensive care plan for one (#53) of five sampled residents reviewed for unnecessary medications. The [NAME] reported the census was 57.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident being administered Furosemide (a diuretic medication) was monitored for electrolyte levels for one (#28) of five sampled resident reviewed for unnecessary medications. The DON stated 12 residents residing at the facilty had been prescribed diuretics.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a CNA (certified nurse aide) changed gloves and cleaned their hand between dirty and clean surfaces for one (#19) of one resident reviewed for pressure ulcers.
June 22, 2023Standard inspection · 5 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent falls for one (#3) of three residents sampled for falls. The facility failed to conduct a root cause analysis, consistently implement interventions to prevent recurrence, and evaluate interventions for effectiveness for a resident who had frequent falls. The Resident Census and Conditions of Resident report documented 45 residents resided in the facility. A Managing Falls and Fall Risk policy, revised December 2007, read in part, .based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. [...]
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5% for one (#25) of five residents observed during medication pass. A total of 25 opportunities were observed with two errors. Total error rate was 8%. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to ensure baseline care plans were completed within 48 hours for one (#47) of 12 sampled residents. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide baths/showers as scheduled for one (#47) of twelve sampled residents. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to administer medications per physician order for one (#25) of five residents sampled for medication administration. The Resident Census and Conditions of Resident report documented 45 residents resided in the facility.
Fire safety inspections
3 fire safety citations on file: 1 on July 17, 2024, 2 on June 22, 2023.
Every fire safety citation3 citations
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 22, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 22, 2023 · Corrected (the home has a date of correction)